The physician’s ubiquitous tool tells stories, if we’d only listen.
One evening I was working alongside an emergency medicine colleague when she surprised me with this confession: she’d been borrowing my stethoscope during ER shifts when I wasn’t on duty. Her stethoscope had vanished months before, and she expressed no immediate plans to replace it. Our white coats shared the coat rack in a tiny room that smelled of whatever Tupperware-mystery was decomposing inside the minifridge. “The earpieces fit my ears just so,” she said of my lower-end Littman, with its rubber missing from around the bell, then let out a gale-force sigh. “Your stethoscope has the spirit of an older physician.”
Older physician? When did that happen? I hoped older implied a wiser physician, someone experienced enough not to waste money on a costly stethoscope.
This ER shift, she was using the magnificent acoustic instrument belonging to another ER physician in our group. “But it’s a younger doc’s stethoscope.” A sly grin hid dismay. “It’s not the same.”
My colleague’s missing stethoscope was as high-end as the one draped over her neck, though she was an older physician, too, and should have known better.
A dizzying assortment of objects have disappeared from ERs. Freshly poured coffee. Donuts sitting on napkins. White coats with the rightful owner’s name stitched clearly over the breast pocket. Mobile phones. Purses. iPads and laptops. Waiting-room cardboard displays promoting services for sexually transmitted infections and substance use. Even heart monitors. Over the years I’ve lost my hair, a permanent state, along with my idealism, which graces me with frequent and quite pleasant visits. So many of my stethoscopes have gone AWOL that I’ve lost count. I’ve noted, however, that stethoscopes are subject to the same gravitational forces as sunglasses and pens. Expensive models float off into the darkest reaches of the galaxy. The modest, functional versions return home like boomerangs.
The ambient sounds that fill ERs—the monitors, the voices, the pain, the ringing phones, the pistons in my brain as I try to think—compete and coalesce into a blanket hum that complicates acoustics and negates the advantages of a premium stethoscope. When noise is everywhere, hearing isn’t the problem, but not hearing: sorting through the sounds and voices, knowing what to tune out and tune in, and hoping you’re making the right choices.
When René Laennec, the French physician and inventor of the stethoscope, rolled a sheath of papers to conduct the chest sounds of a young woman on rounds in 1816, he ushered in a vibrant era of modern medicine. Derived from the Greek stethos for “chest” and skopos for “observer,” the stethoscope has symbolized my chosen career more than any other instrument. The stethoscope I received on entering medical school embodied all the knowledge and skills I was responsible to master. It represented the gravity and immensity of my future life’s work, more so than the white coat, which always felt like a starchy straitjacket, a persona that never fit me properly.
The stethoscope is more than a piece of medical equipment. It provides an opportunity for personal expression. Pediatricians hang furry creatures from the tubing like it’s a tree limb in paradise. Young physicians sport delicious colors such as raspberry, peach, and orange. Physicians who served with the Indian Health Service often adorn their tubing in intricate, Native American handiwork, like tight sweaters on handbag dogs. Internists and cardiologists bear the stethoscope with a quiet swagger, as if it’s Indiana Jones’s whip, a tool capable of rooting out the wiliest heart murmur, disarming the most combative surgeon, and pulling them out from a pit of poisonous snakes. The orthopedists, meanwhile, stride like proud nudists, not knowing when the last time they wore a stethoscope or where it was hidden should they ever need it.
For those of us who use a stethoscope as part of our daily work, it becomes a body part. That my colleague found comfort placing my earpieces inside her ears made me uneasy. It’s hard to explain. Our relationship with certain objects can become personal, and they don’t share well with others for reasons that aren’t always logical. Baseball hat? Sure. Baseball mitt? Umm. A five iron? Go ahead. A putter? Over my dead body. Shirt? I guess. Underwear? Yuck. I’m fascinated by the transgressions I accept as normal. For example, I tolerate the odors, secretions, and decay of sick and unfortunate bodies in my work, and yet I get the creeps each time I squeeze my feet into rented bowling shoes.
So much of being a physician involves sharing experiences, both personal and clinical, that are disorienting: mistakes in judgment or behavior; opportunities lost through doubt or fear or fatigue; even successes that shocked us. The expanse of medicine is daunting and complicated. We must, by necessity, learn from the experiences of others. Medical school and residency for me involved being on call every third or every fourth night, but many of my teachers boasted of working every other night at the hospital. They’d ask, “Do you know the worst part of being on call every other night?” The answer was always: “You miss half the interesting cases.”
My stethoscope had acquired talismanic properties, timeearned luck, along with a memory of the thousands of patients we’d listened to together. During critical moments when uncertainty or panic pushed into my head, my trusted stethoscope helped focus my attention. Slow down and close your eyes, it advised me. We’ve been here before. Listen to what the body is telling you, and what it’s not.
With time, the stethoscope becomes your child, and a loving, responsible parent doesn’t share his child with anyone else. But my colleague had my blessing to continue plundering the pocket of my white coat. She’s a wonderful parent. She and her partner have all boys, and one has autism spectrum disorder. She has the patience, the resolve, the tested love that makes me strive to be a better person. Wouldn’t my stethoscope benefit from working with someone more understanding and patient, who engaged the most challenging patients without judgment or an edge to her voice?
In turn, when my stethoscope sat around my neck, I could channel my colleague’s nuclear-powered empathy. The stethoscope we shared didn’t make me a better doctor; it allowed me to tap into that place in me where a more emotionally evolved doctor could be found.
Regardless of how old, wise, or kind you are, there is always room to do it better the next time. To that end, you must listen to your own heart before you can listen to others. It starts with relinquishing ego. Becoming an older physician requires being humbled again and again. The body doesn’t read the textbooks, and it’s safe to assume patients haven’t read the script you want them to follow. There’s only one true way to become an excellent doctor, and that’s to take care of patients, an endless train of them. And when each situation feels new and particular, unsettling and surprising, you must be open to being startled.
Teachable moments and pricks of insight often strike without warning, usually outside the knowledge delivery systems such as lecture halls and ward rounds. Nurses and ward clerks, social workers and translators, security guards and housekeepers have all been my teachers. They have offered winking approvals and cast a hot spotlight on behaviors, attitudes, and actions that “weren’t me.”
Patients have been my greatest teachers: this is how you die with grace; this is how you survive on the streets; this is how you don’t talk to me; this is how you earn my trust.
When I first entered medical school, awestruck by the stethoscope, I never imagined the most influential teacher in my medical career would come in the form of the late Walter James Miller, a New York University professor, author, and poet. He was not a physician. His mentorship, and later friendship, began during my year away from medical school to write. He knew that to write well, you must first write poorly. But you must write. He rarely took a sharp knife to my prose though it deserved a samurai. Years later, I accused him of being too kind to my early work. He said I wasn’t ready for that type and depth of criticism. First, I needed encouragement, room to find my voice, and permission to stay true to what he knew was so important to me. He shepherded the conditions so I could discover what I needed to learn. Only now, thirty years later, do I recognize mentoring so deftly wrought I didn’t know it was going on. I’ve “borrowed” more from his mentoring style than from any other physician/educator.
I’m now an older physician and still a work in progress, thirsty for ways to become a better version of myself.
What does this have to do with my beat-up stethoscope?
Despite its many functions as instrument, adornment, and friend, my cheaper stethoscope is limited as a unidirectional conductor of the body’s sounds. It captures narrative fragments, tiny statements. What matters is how we translate these sounds, intellectually and emotionally, into meaningful action. Listening through and around the earpieces of my cheaper stethoscope—an idea that winks at Laennec’s original definition of the stethoscope as a chest observer—might offer the best way to reconcile sound, silence, and suggestion into a coherent story.
There are dangers to becoming a high-end stethoscope. The writer/critic Anatole Broyard said it best: “There is a paradox here at the heart of medicine, because a doctor, like a writer, must have a voice of his own, something that conveys the timbre, the rhythm, the diction, and the music of his humanity that compensates us for all the speechless machines.”
Eric Topol, a world-renowned cardiologist and thinker on the transformational role of technology in medicine, called the stethoscope nothing more than a pair of “rubber tubes.” The next-generation stethoscope is an ultrasound machine that transmits images to a screen, not sounds to our ears. Instead of detecting a heart murmur and connecting it to the anatomical abnormality it signifies, we can visualize the anatomy directly. But the body isn’t replicated like a photograph; it’s represented on the screen as acoustic signals in a spectrum of white, black, and grays. The details are identified through skilled interpretation of shadows.
I frequently wonder whether the death knell for the stethoscope isn’t too far off, and the next time my stethoscope vanishes, should I bother replacing it?
This isn’t a theoretical question. The COVID-19 pandemic has changed how we use the stethoscope. We’ve altered acceptable practices to minimize the risk of infecting ourselves or transmitting the SARS-CoV-2 virus to others. Most stethoscopes aren’t six feet long. If we need to, we use disposable versions that we assemble and keep in the room. I suspect Laennec’s rolled sheath of papers worked better as a transmitter of sound. But when a patient is working hard to breathe, it feels awkward and irresponsible not to place a stethoscope to their chest. For all the diagnostic utility of ultrasound, especially during the pandemic, it lacks the iconic force of the stethoscope. The ultrasound can pick up fluid around the heart and lungs, detect how strong the heart is pumping, but the stethoscope speaks to patients—I’m right here.
The practice of medicine is nuanced and oblique. It needs personalities willing to take fully authentic breaths. Better technology won’t necessarily replace what humans need most from each other: the promise of connection. I might not be perfect, but I’ll be present. After all these years, I’m still working on finding my voice in medicine. Patients continue to surprise me, and as a consequence, I continue to surprise myself. I’ve become more comfortable with that, as I was with sharing a stethoscope with a colleague I respect so much. She eventually moved on to another job that rewarded her remarkable clinical and teaching skills, and I moved on as well. My stethoscope vanished. I’d like to imagine a younger physician using it, channeling the experience of two older physicians while acquiring and accumulating their own, but I’m doubtful. It was only a fair conductor of pure sounds. But if you knew what to listen for, there was no better guide.